Recipient

Mental Health Act assessors

First report 25 Oct 2016•Latest report 25 Oct 2016

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Mental Health Act assessors linked to the concerns in each report. Select any concern, action or position to view the source wording.

25 Oct2016
Inner South London
Concerns raised6
1. Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
2. Failure of detained organisations to pass risk information consistently between one another
3. Inadequate nurse assessment of fitness for segregation
1. Lack of an agreed system for transferring health care information from police stations or courts to prisons
2. Inadequate standard of Mental Health Act assessments
3. Lack of clear responsibility for passing or seeking relevant information
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Richard Walsh · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report
“There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Failure of detained organisations to pass risk information consistently between one another
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Inadequate nurse assessment of fitness for segregation
Wider context from the report
“3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Lack of an agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Inadequate standard of Mental Health Act assessments
Wider context from the report
“2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mental Health Act assessors; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear responsibility for passing or seeking relevant information
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion

Failure of detained organisations to pass risk information consistently between one another

Inadequate nurse assessment of fitness for segregation

Lack of an agreed system for transferring health care information from police stations or courts to prisons

Inadequate standard of Mental Health Act assessments

Lack of clear responsibility for passing or seeking relevant information